A small, randomized, single-blind controlled trial studied 160 Australian children between 7 and 11 years of age with bilateral flexible excess pronation (everted calcaneous and lowered medial transverse arch) associated with weight bearing. The investigators evaluated gross motor proficiency, self-perception, exercise efficiency, and pain over 12 months in 3 groups of children who received no treatment, noncustom orthoses, or custom-made orthoses. They found no significant difference in any outcomes measure among the groups after 3 and 12 months.5
Better results with heel cups than insoles
A small (N=30) retrospective study enrolled children (mean age 3.8 years) based on clinical and anatomical characteristics of FFF. The study found that a polyethylene “dynamic varus heel cup” worn for 14 months was superior to static insoles for treating severe pes planus, characterized by poor formation of the longitudinal arch and valgus deviation of the calcaneous. The study was not randomized or blinded, and the authors evaluated only physical examination features and radiographic findings, not patient symptoms or functional outcomes.6
Rigid flatfoot often causes symptoms
RFF is often symptomatic and is caused by underlying pathology.7 Tarsal coalition is the most common cause, but trauma, neoplasm, infection, and rheumatologic and neuromuscular disorders can all contribute. A very small retrospective study of 9 patients found that “children and adolescents with painful idiopathic rigid flatfeet…can have significant, persistent disability.”8
Surgical treatment depends on underlying pathology
No long-term studies similar to studies of FFF have compared surgery with conservative therapies for RFF. The type of surgical treatment used depends on the underlying pathology and which planes of the foot are affected.9 Surgery may include 1 or more of the following procedures, depending on clinical and radiographic evaluation:
- tendon transfers or lengthening
- tarsal arthrodeses or subtalar joint motion blockers
- calcaneal osteotomy.
Several small studies of different surgical treatments found varying degrees of radio-graphic and symptomatic improvement. None reported long-term outcome data, however.
Recommendations
A Cochrane review of interventions for pes planus is in process.
Recommendations from the Clinical Practice Guideline Pediatric Flatfoot Panel of the American College of Foot and Ankle Surgeons state that “most flexible flatfeet are physiologic, asymptomatic, and require no treatment. Physiologic flexible flatfoot follows a natural history of improvement over time. Periodic observation may be indicated to monitor for signs of progression. Treatment is generally not indicated.”9
If FFF is symptomatic, “initial treatment includes activity modifications (primarily avoiding painful activities), stretching, foot strengthening exercises, and orthoses. When all nonsurgical treatment options have been exhausted, surgical intervention can be considered.”9
Regarding RFF, the panel notes that the condition “can be symptomatic or asymptomatic. Most cases are associated with underlying primary pathology” and its treatment. “Surgical consideration should be given to those who fail to respond to nonsurgical treatment.”9 Tendon transfers and tendon lengthening are not recommended for children.